The title of this post comes from a speech from Columbia health policy and management professor Lawrence Brown. For years, Presidents and other politicians have noted that rising health care costs will lead to the collapse of the system. Michael Millenson highlights this state of unending crisis in his Health Affairs blog post titled “Half A Century Of The Health Care Crisis (And Still Going Strong).” It is of particularly of interest in looking at the consistency of how President’s have messaged rising health care costs:
on July 10, 1969, President Richard Nixon proclaimed, “We face a massive crisis in this area.” Without prompt administrative and legislative action, he added at a special press briefing, “we will have a breakdown in our medical care system.”…the Obama administration warned in year 41 of the crisis (2009): “Soaring health care costs make our current course unsustainable.” In year 50 (2018), the Trump administration used nearly the same language, declaring, “The system we have is unsustainable, and it cannot continue.”
Millenson’s article is thoughtful throughout and touches not only on the issue of cost, but also on quality and access issues. The article concludes as follows:
“Everyone seems to agree that the existing system—or lack of system—has rather marked shortcomings,” Gardner complained plaintively. “But there is not yet any agreement as to what a more perfect system will look like.”
A perfect system there will never be. When I started in practice over 20 years ago, it was trillion dollar pie. It has progressed to 2 and then 3. Physicians and fee-for-service have been blamed, but I suggest this is a misreading of the reality. Publicly traded for-profit entities in a position of constraining costs (insurers, PBM’s) have an irreconcilable conflict of interest, but a single payer system would have its own global budget rigidity. The shifting of payor systems is not the issue. Creating effective regulation of the different domains is necessary, with hospitals, physicians, labs and ancillary technologies, and biopharmaceuticals all having different realities to them. For the latter, we want innovation but can’t afford to pay back the cost in the window of patent exclusivity. Thus, we have an extremely dysfunctional and unfair system that is gamed on the backs of patients, physicians, and those who pay premiums (employers, taxpayers, and individuals). I strongly encourage addressing this latter failure as a step that can help move us to a soft landing. The carrot of long-term licensure for drugs and technologies combined with price regulation via Medicare would restore clinical autonomy, reduce bureaucratic tangles, and have an opportunity to bring returns more in line with true clinical benefit. Closed formularies, financial coercion, high co-pays, and exclusivity arrangements are not an ethical solution, even though that is where so much of the literature is focused. It is time to listen to those at the front line and stop the experimenting.